Laparoscopic repair of a Morgagni hernia presenting with syncope in an 85-year-old woman: case report and update of the literature

Syncope: Atypical Presentation of Diaphragmatic Hernia

In this case report, we describe a rare presentation of diaphragmatic hernia in a pediatric patient presenting with syncope. Congenital diaphragmatic hernia (CDH) is a developmental discontinuity of the diaphragm that causes the abdominal viscera to herniate into the thoracic cavity. It is usually diagnosed shortly after birth and is often associated with pulmonary hypoplasia and pulmonary hypertension, causing life-threatening conditions, or it could be completely asymptomatic. Syncope is induced by various conditions such as cerebrovascular disease, arrhythmia, hypoglycemia, anemia, epilepsy, and autonomic nervous disorder.

Pericardial Effusion Can Be a Critical Complication After Laparoscopic Hernia Repair Using Mesh and Stapler for Morgagni Hernia

Several cases of Morgagni hernia have recently been treated with laparoscopic mesh repair, which is reported to have fewer complications and to be less invasive. Here we describe a case of a laparoscopic Morgagni hernia repair treated with mesh that progressed to heart failure due to pericardial effusion 2 months after hospital discharge. A 78-year-old woman was incidentally found to have a Morgagni hernia during a routine chest X-ray. The laparoscopic Morgagni hernia repair was performed using Composix mesh and an ENDOPATH EMS stapler. The Composix mesh was gently attached to the surface of the diaphragm using the ENDOPATH EMS stapler. She was discharged from the hospital on the seventh postoperative day without any adverse events. However, 2 months later, she developed dyspnea due to heart failure secondary to a pericardial effusion. Pericardial drainage was performed during her hospitalization, and she was discharged 7 days later. No recurrence of either the pericardial effusion or the Morgagni hernia has been detected since the pericardial drainage. Clinicians may need to be aware of the risk of pericardial effusion in these cases, even if there has been no damage to the diaphragm or epicardium.

Intestinal Tamponade

Concurrence of a congenital Morgagni hernia and paraesophageal hernia is rare and can occasionally present as a medical emergency. Here, we report a unique case of a patient with paroxysms of cough-induced syncope secondary to cardiac compression by a simultaneously occurring anterior Morgagni hernia and posterior paraesophageal hernia.

Right-sided diaphragmatic rupture after repair of a large Morgagni hernia

We present a case of a combination of primary and secondary diaphragmatic hernia in a 63-year male patient. For progressive dyspnea and palpitations caused by a large and symptomatic Morgagni hernia resulting in a right-sided enterothorax, an open tension-free mesh repair was performed. The postoperative course was complicated by a secondary hepatothorax through a spontaneous rupture of the right diaphragm. Primary mesh repair of the Morgagni hernia, however, proved to be sufficient. This recurrent herniation might be a consequence of (1) preexisting atrophy of the right diaphragm caused by disposition and/or long-term diaphragmatic dysfunction due to the large hernia, combined with (2) further thinning out of the diaphragm by intraoperative hernia sac resection, and (3) postoperative increase of intra-abdominal pressure.

Laparoscopic repair of congenital diaphragmatic hernia complicated with sliding hiatal hernia with reflux in adult

INTRODUCTION

Congenital diaphragmatic hernia (CDH) in adults is a relatively rare condition being asymptomatic in the majority of cases. Symptomatic CDH should prompt surgical management because they may lead to intestinal obstruction or severe pulmonary disease. This is the first reported case of a symptomatic CDH complicated with sliding hiatal hernia (SHH).

PRESENTATION OF CASE

A 65 years old women with reflux and dysphagia was complaining of postprandial paroxysmal dyspnea and epigastric pain radiating to her back. Upper endoscopy diagnosed sliding and para-esophageal diaphragmatic hernia with severe esophagitis. Computed tomography-scan revealed a large Bochdalek hernia at the left diaphragm.

DISCUSSION

Diagnostic laparoscopy was decided, which confirmed the SHH, but also revealed a CDH defect at the tendonous part of the left diaphragm. The left bundle of the right crus was intact, separating the two hernia components (sliding and congenital). Extensive adhesiolysis was performed, dissecting and separating the stomach away from the diaphragm. Posterior cruroplasty at the esophageal hiatus was performed for the SHH with Nissen fundoplication as antireflux procedure. Primary continuous suture repair was performed for the CDH, reinforced with prosthetic mesh on top. Operative time was 150min with no morbidity. The patient was discharged home uneventfully the third postoperative day. On 12-months follow-up, she reported no symptoms and improvement in quality of life.

CONCLUSION

Laparoscopy is a unique method for a precise diagnosis of symptomatic congenital diaphragmatic hernia in adults being also a safe and viable technique for a successful repair at the same time. Experience of advanced laparoscopic surgery is required.

Foramen of Morgagni hernia: presentation and treatment

Morgagni hernias are rare and most often asymptomatic. However, there is always a concern about strangulated bowel. Diagnosis is usually by chest radiograph or CT scan. The surgical approach may be either transabdominal or thoracic. There are increasing reports about the role of minimally invasive approach. The recurrence is low with an excellent prognosis.

Laparoscopic repair of Morgagni hernia

BACKGROUND

Foramen of Morgagni hernias are rare diaphragmatic hernias. They account for 3-5% of all diaphragmatic hernias and the majority of the cases are asymptomatic. They are caused by trauma, obesity or pregnancy. With the advancements of laparoscopic surgery, laparoscopic repair has become an excellent alternative to open repair for Morgagni hernias. We report five cases of Morgagni hernia repaired with the laparoscopic approach in conjunction with a review of the literature.

PATIENTS

A retrospective review comprised five patients who had a Morgagni hernia repaired with a laparoscopic approach. Data from these patients were collected for the period between February 2001 and May 2005.

RESULTS

The average age at operation was 61. The anatomic pathology was detected preoperatively using X-rays and computerized tomography (CT) scans in four of our patients. Hernia was detected incidentally in one patient during an elective cholecysectomy. Three hernias were right-sided and two were left-sided. The contents of the hernias were omentum and transverse colon in the majority of the patients. The hernia was repaired with a laparoscopic approach in all patients. Four patients had composite mesh repair and one patient had primary closure with nonabsorbable sutures. There were no postoperative complications and all patients tolerated laparoscopic repair. There were also no recurrences during follow-up.

CONCLUSIONS

Laparoscopic repair is a candidate to be a standard treatment for Morgagni-type hernias. It is an effective and safe technique and can be performed by all compotent general surgeons with a certain learning curve. It has several advantages relative to the open operation.

Laparoscopic repair of diaphragmatic hernias: experience of six cases

OBJECTIVE

Laparoscopic diaphragmatic hernia repair is increasingly performed in adults for congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias. This study reviewed our experience with laparoscopic diaphragmatic hernia repair to evaluate its safety, efficacy and outcomes.

METHODS

Between January 1999 and December 2002, four male and two female patients presented to us with diaphragmatic hernias, three with traumatic and three with congenital hernias. The mean age of patients was 58.6 years (range, 42-83 years). Five patients presented with main complaints of postprandial retrosternal/chest discomfort and one patient had an acute gastric outlet obstruction. Dissection was performed laparoscopically to reduce the contents of the sac and the hernial defect was repaired using prolene sutures and a polypropylene mesh.

RESULTS

Laparoscopic repair of diaphragmatic hernias was completed successfully in all patients. The mean size of the defect was 6.8 cm (range, 3-12 cm) and the mean operative time was 100 minutes (range, 60-150 minutes). There were no major intraoperative complications. One patient required placement of a chest tube due to inadvertent opening of the pleura with the hernial sac and one patient had prolonged postoperative gastric ileus. The mean hospital stay was 2.3 days (range, 1-4 days) and the mean pain score was 4 (range, 2-6). All patients remained asymptomatic over a mean follow-up of 2.9 years.

CONCLUSION

Adult congenital and chronic traumatic diaphragmatic hernias are amenable to laparoscopic repair. Laparoscopic repair is safe and feasible and confers all the advantages of minimal access surgery.

Clinical presentation and operative repair of hernia of Morgagni

A 77 year old woman who presented with an incarcerated hernia of Morgagni was successfully treated without complications. A Medline search (1996 to date) along with cross referencing was done to quantify the number of acute presentations in adults compared to children. Different investigating modalities--for example, lateral chest and abdominal radiography, contrast studies or, in difficult cases, computed tomography or magnetic resonance imaging--can be used to diagnose hernia of Morgagni. The favoured method of repair--laparotomy or laparoscopy--is also discussed. A total of 47 case reports on children and 93 case reports on adults were found. Fourteen percent of children (seven out of 47) presented acutely compared with 12% of adults (12 out of 93). Repair at laparotomy was the method of choice but if uncertain, laparoscopy would be a useful diagnostic tool before attempted repair. Laparoscopic repair was favoured in adults especially in non-acute cases.

Massive Recurrent Anterior Diaphragmatic Hernia, Coronary Artery Disease, and Valvular Heart Disease

We report the case of a 76-year-old woman found on preoperative evaluation for vaginal prolapse to have coronary artery disease, aortic stenosis, and a large recurrent anterior diaphragmatic hernia. The clinical presentation and surgical management of this case, and the review of the literature are discussed.

[Diaphragmatic hernia of Morgagni-Larrey in adults: analysis of 10 cases]

Congenital diaphragmatic hernia of Morgagni-Larrey is a rare entity that usually presents on the right side. These hernias, occurring in the anterior midline through the sternocostal hiatus of the diaphragm, are usually discovered incidentally when the patient has reached adulthood, or when they become symptomatic due to intestinal involvement (occlusive symptoms) or when respiratory dysfunction occurs. We present 10 patients (mean age: 69 years) with symptomatic sternocostal hernia and intestinal occlusion. In 7 patients, the hernia was located on the right (Morgagni's hernia) and in three it was located on the left (Larrey's hernia). Most of the patients presented important associated comorbidity, mainly cardiovascular and neoplastic. Surgical treatment consisted of reduction of the contents of the herniated sac and hernia repair through simple suture with or without mesh for reinforcement, mainly through the abdominal approach. Mortality in this series was nil. The infrequency of this entity and its diagnosis mainly in adults, with a high prevalence of circumstances favoring abdominal hernias, suggest that an embryological defect of the sternocostal foramina of Morgagni or Larrey are an essential element in the physiopathology of these processes.

Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned

BACKGROUND

Minimally invasive surgery (MIS) for the repair of congenital diaphragmatic hernias (CDH) had been described. This report reviews the authors' experience with MIS repairs of CDH and discusses the technical development of this approach.

METHODS

From 1999 until now, the authors collected data on children who underwent an MIS approach for CDH repair.

RESULTS

Seventeen children (11 Morgagni and 7 Bochdalek) had undergone an attempt at MIS repair. All Morgagni defects were treated successfully using laparoscopy (mean age, 28 +/- 31 months). Mean follow-up was 22 +/- 9 months. There was 1 recurrence. Four children with Bochdalek CDH were treated as newborns (range, 3 to 21 days), and 3 had operations later (4, 11, and 32 months). The first repair was attempted initially transabdominally and was converted to a thoracoscopic approach. The rest of the Bochdalek repairs were performed thoracoscopically. Bochdalek repairs via MIS were successful in 3 children (2 older children and 1 neonate). No child had pulmonary hypertension. Two of the 3 Bochdalek patients did well postoperatively (follow-up, 18 +/- 7 months); the last patient experienced recurrence 11 months after repair.

CONCLUSIONS

MIS for CDH is ideal for Morgagni defects. It should be considered for nonnewborns with a Bochdalek CDH. The MIS approach for a newborn with a CDH cannot be recommended because of the high failure rate and frequent rise in PCO2 levels.